Nurse-led oral and maxillofacial oncology clinics: a review

The “nurse-led” oral and maxillofacial (OMFS) head and neck (H&N) clinic has been introduced and developed over the last decade, and we are now close to a point that this endeavour can potentially be implemented nationwide. This paper is a systematic review of the proposed OMFS H&N nurse-led clinic model. Literature on the topic is limited: only eight eligible papers were identified and reviewed. These were appraised focusing on four domains: requirement/necessity, true cost, patient safety and outcomes, and education and training. Most of the advantages/proposed benefits of these clinics have previously been discussed. This current review has revealed that the available published evidence on the concept of OMFS H&N nurse-led clinics demonstrates that they might not be necessary. The alleged cost savings have not been described in detail and might not be as significant as expected, more intense collaboration is required to establish watertight quality assurance processes concerning patient safety, and the clinics might have an impact on the education and training of OMFS trainees. The nurse-led clinic concept is interesting and exciting, but more discussion and planning is needed prior to it being launched nationwide.     

Treatment anxiety in oral and maxillofacial surgery. Results of a German multi-centre trial.

BACKGROUND: Oral and Maxillofacial operations can be extremely frightening treatment situations. General data on this phenomenon should be acquired through a multi-centre trial. METHOD: A 10-page questionnaire was developed which was answered by 600 oral and maxillofacial patients before individual treatment. Control groups consisted of 800 surgical, dental and general practitioners/internal medicine patients. Twenty six medical practices and hospital departments in 11 German cities were involved in the trial. RESULTS: Both subjective anxiety assessment by patients and objective testing (State Trait Anxiety Inventory; STAI) indicated a high level of treatment anxiety for oral and maxillofacial treatment situations. Oral and Maxillofacial Surgery (OMFS) patients' scores were significantly higher than those of control groups. Especially younger and female patients, patients treated under local anaesthesia and out-patients showed intensive anxiety. Previous treatment experience in OMFS did not modify test results. CONCLUSION: Managing perioperative anxiety is still a major challenge in OMFS. Irrespective of technical, pharmacological and surgical advances, developing and establishing stress-reducing and anxiolytic perioperative techniques is of considerable importance for both patients and surgeons.     

Dental treatment of a patient with Friedreich's ataxia

The dental treatment of a patient with Friedreich's ataxia is discussed. Despite the patient's systemic conditions, treatment including oral hygiene instructions and an extraction was performed without complications. With knowledge of this disease, in conjunction with medical consultation, these patients can be treated successfully.     

Qualitative comparison of curricula in oral and maxillofacial surgery training. Part 1: dental foundation training

Dental foundation training (DFT) is a two-year programme being introduced for new dental graduates. It is not currently compulsory but there are plans to make it so. Those studying oral and maxillofacial surgery (OMFS) must complete both medical and dental degrees, and training, and if DFT becomes a requirement for dental registration, the process could be lengthened. We aimed to examine the overlap between DFT and medical foundation and core surgical training, to highlight areas of potential duplication for those who completed their surgical training before graduating from dental school. Relevant curricula for OMFS trainees were identified and compared with the DFT curriculum, and a qualitative assessment tool was developed to measure overlap between non-analogous curricula. Depending on previous experience, an OMFS trainee who completed core training in surgery before studying dentistry may already have covered 76% of the DFT curriculum. Areas with the least duplication in clinical skills (53%) were notably those related to restorative dentistry, prosthodontics, and periodontology, but there was considerable overlap in non-clinical areas such as communication skills (100%) and professionalism (90%). A method of standardised assessment of previous experience may allow for DFT to be shortened for OMFS trainees.     

Update on dental graduates entering medicine 1986-1991

In a previous publication we reviewed the future career plans of 169 dental graduates who entered medical school from 1986 to 1991 inclusive. The aim of the present study was to find out what happened to this group after qualification from medical school.The 169 individuals were traced and a questionnaire was sent to them by mail. A reminder was sent and some data for non-respondents were obtained from public sources such as registers and directories.In the original study, 120 of the 154 respondents (78%) intended to become oral and maxillofacial surgeons. We found in this follow up survey that the overall return rate to oral and maxillofacial surgery (OMFS) had dropped to 66%. For those not returning to the speciality, a wide range of alternative specialities had been chosen, with general medical practice (n=9) and oral medicine (n=8) being the most popular.Amongst those returning to OMFS, most undertook basic surgical training in general surgery and trauma. Two thirds of those eligible possessed the FRCS, with 43 (83%) holding the FRCS (Clinical Surgery in General) and six (12%) having the FRCS Ed (oral and maxillofacial surgery).Within the group, opinions were mixed about the changes caused by 'Hospital doctors: training for the future' (Calman Report) [Working Group on Specialist Medical Training. Hospital doctors: training for the future. London: Department of Health, 1993]. Concerns were voiced about the potential reduction in clinical experience, comparatively longer training for OMFS, and particularly the abrupt end of training with no protection whilst seeking a consultant appointment. Half thought that OMFS will become concentrated in supraregional centres, or head and neck units with related specialities.     

Duchenne muscular dystrophy: a report of case

Duchenne muscular dystrophy is a debilitating disease that includes significant medically and physically disabling conditions that have an effect on the dental treatment of these patients. The dental treatment considerations for the patient with Duchenne muscular dystrophy include: the current status of the disease; the progressive nature of the disease; lack of ambulation; poor muscular control and muscle weakness; muscle contractures; respiratory and cardiac complications; relative contraindication of general anesthesia; and the oral health needs of the patient. In the case reported, these problems were considered and appropriate treatment modalities selected. With appropriate medical consultation and ample consideration of the patient's physically disabling conditions, dental therapy can be modified to provide a satisfactory level of oral health for the patient with Duchenne muscular dystrophy.     

Management of odontogenic cervicofacial infections presenting to oral and maxillofacial units during the first wave of the COVID-19 pandemic in the United Kingdom

On 25 March 2020, the Chief Dental Officer issued national guidance restricting the provision of all routine, non-urgent dental services in response to the spread of COVID-19. We analysed odontogenic cervicofacial infections (CFI) presenting to oral and maxillofacial surgery (OMFS) departments during the first wave of COVID-19 in the United Kingdom.From 1 April 2020 until 31 July 2020 a database was used to prospectively collect records for all patients with CFI who presented to oral and maxillofacial teams. Information gathered included clinical presentation, location/origin of infection, and how this was managed. The OMFS units were asked to compare the patient’s care with the treatment that would usually have been given prior to the crisis. A total of 32 OMFS units recorded 1381 cases of CFI in the UK. Most of the infections were referred via the emergency department (74%). Lower first or second molars were the most common origin, contributing 40% of CFI. Collaborators reported that patients' treatments were modified as a response to COVID in 20% of cases, the most frequently cited reason being the application of COVID-19 hospital policy (85%). The impact of the first wave of COVID modified the management of a significant number of patients presenting with CFI, and there was a proactive move to avoid general anaesthetics where possible. Some patients who presented to secondary care were given no treatment, suggesting they could have been managed in primary dental care if this had been available. We recommend that OMFS units and urgent dental care centres (UDCCs) build strong communication links not only to provide the best possible patient care, but to minimise COVID exposure and the strain on emergency departments during the pandemic.     

The specialty of oral and maxillofacial surgery (OMFS) in Europe – Part 1: service configuration,regulation, and provision

Oral and maxillofacial surgical (OMFS) practice and training in Europe is supported by the OMFS Section of the Union of European Medical Specialists (UEMS). Across Europe the number of OMFS specialists per 100,000 varies from 3.0 (Switzerland) to 0.28 (Ireland). The two types of OMFS within the European Union (EU) under Directive 2005/36 and European Free Trade Association (EFTA) treaties are dual degree dental, oral and maxillofacial surgery (DOMFS) and single medical degree maxillofacial surgery (MFS). Automatic recognition of OMFS specialist qualifications is possible only between nations which have the same (or both) types of medical OMFS. Otherwise, individual specialists must apply for a Certificate of Eligibility for Specialist Registration (CESR). DOMFS: 20 European nations have dual degree OMFS. Of these, 12 EU nations are DOMFS in Annex V, 3 are DOMFS in the European Free Trade Association (EFTA) Treaty, and one has mandated dual degree OMFS but is a dental specialty. The United Kingdom has dual degree OMFS. Two MFS nations have had mandated dual degree training for more than 10 years and one has both DOMFS and MFS training, with DOMFS recommended. Although no nation with dual degree DOMFS has transitioned back to single degree MFS, there are pressures to do so within Finland and Norway. MFS: 11 EU nations have single medical degree MFS (and 4 DOMFS nations also have MFS as a legacy specialty). Four nations in the EU/EFTA do not yet have a medical specialty of OMFS: Sweden, Iceland, Denmark, and Estonia.     

Legislation for Oral and Maxillofacial Surgery (OMFS) in the UK lags behind the patient care we provide: an illustrative timeline and recommendations for the future

OMFS is the surgical specialty which bridges dentistry and medicine. As the specialty of OMFS emerged from the dental specialty of Oral Surgery during the 1980s the Dentists Act 1984, whose purpose included preventing medical practitioners providing unregulated general dental care, was published. In 2008 the Postgraduate Medical Education and Training Board (PMETB) review of training in OMFS concluded that dual qualification was essential and recommended that OMFS specialists should only be required to register with one regulator, the General Medical Council. For OMFS to continue to provide high quality patient care, and to help the GDC and GMC in their roles regulating our specialty, BAOMS has identified 5 areas for regulatory change: (1) All OMFS specialists should be able to practice the full curriculum of OMFS with only GMC registration if they wish to – this was recommendation 4 of the PMTEB Review of OMFS in 2008. (2) If an OMFS specialist or trainee is registered with both the GMC and GDC. (3) A Memorandum of Understanding between the GMC and GDC should prevent any fitness to practice concerns being processed by both regulators. (4) Dually registered OMFS specialists should be able to indicate that they have had “appraisal of the full scope of practice” to comply with GDC Continuing Professional Development (CPD) regulations. (5) Oral Surgery specialist list should retain Route 11 for OMFS specialists as the Oral Surgery Curriculum is entirely within the OMFS curriculum. Legislative changes may be the best route to deliver these recommendations. Until these changes happen, the GMC, GDC and BAOMS should work together in the best interests of patients.     

Attitude of clinical medical students to Oral and Maxillofacial Surgery as a career: a perspective from two English Medical Schools

Oral and Maxillofacial Surgery (OMFS) has been increasing in popularity amongst medicine first trainees. Despite this, there is still limited exposure at the undergraduate level. This study aimed to: evaluate the experience of medical students in the field of OMFS, the awareness of medical students to OMFS resources/societies and to determine the greatest motivators and deterrents for students in pursuing a career in OMFS. An online survey was distributed to 198 students spread across two English universities. 131 students (66.2%) were from University A and 67 (33.8%) students were from University B. A total of 61.1% of undergraduate medical students had no exposure to OMFS up until their current stage of training with no statistically significant differences in OMFS exposure between the year groups (p>0.05). 37% of students considered OMFS as a potential career path with dual qualification being the deterrent in 44% of cases. 97.0% of students were not able to state any organisations/resources available to support them in pursuing a career in OMFS. Within our cohort exposure to OMFS was greater than earlier reports, however; undergraduate exposure to OMFS is still very limited in UK medical schools. Conducting a dental degree following the primary medical qualification appears to be the greatest obstacle to students considering OMFS training. OMFS remains unknown to medical students and healthcare professionals. We need grass root changes at undergraduate level to improve the future of OMFS training.     

Complications due to the waiting period for dental treatment under general anaesthesia

The capacity for dental treatment under general anaesthesia is limited. Clearly, the demand for treatment exceeds the supply. A written questionnaire completed by all 403 patients who were treated in 2003 in a centre for special dentistry under general anaesthesia, or their parents or carers, revealed that the median time between referral and the first consultation was 8 weeks. The median time between the first consultation and treatment was also 8 weeks. The waiting period for children was longer than that for adults, with that for 4- and 5-year-olds the longest of all. During the waiting period, 43% of the patients developed complications, such as oral pain and problems with eating and sleeping. Children developed complications more often than adults. With every week of waiting, the likelihood of children developing complications increased by 6.7%.     

A review of oral and maxillofacial surgery journals’ contribution to undergraduate surgical education

We searched the Medline database of 4 leading international journals of oral and maxillofacial surgery (OMFS) for all articles containing the terms “undergraduate”, “medical student”, or “dental student” in the abstract, title, or keywords, from the earliest paper to 2013, to identify and review publications that related to the education of undergraduate medical and dental students. We found 130 articles, of which 22 (17%) met the inclusion criteria. Most were published by teams based in the United States, followed by those from the United Kingdom and Germany. The earliest was published in 1986. Since then, most have been published in the Journal of Oral and Maxillofacial Surgery (0.33/year) and the least in the International Journal of Oral and Maxillofacial Surgery (0.11/year). Eleven original research articles concerned dental students and 4 concerned medical students. Three studies looked at both groups and compared them with their qualified counterparts. There is a relative paucity of articles relating to the education of undergraduates, particularly medical students, in OMFS journals, although the number has increased over the last decade. There is a need for more educational papers to be aimed at students interested in pursuing OMFS as a career.     

Complementary and alternative medicine usage by patients of a dental school clinic

This pilot study investigated the prevalence and specific reasons for usage of complementary and alternative medicine (CAM) among patients of a dental school clinic. Four hundred and two patients completed a 30‐page survey on CAM usage. A higher rate of CAM usage was found in this dental school clinic population than rates previously reported in a general population. More than three‐quarters (76.1%) of the respondents reported using at least one CAM treatment in the past 12 months; 93.3% reported using at least one CAM treatment at some time in their lives. High rates of chiropractic use were found in this population. Tooth pain was the most frequently reported dental condition motivating CAM use. About 10% of dental school clinic patients use topical oral herbal and/or natural products to treat dental conditions, most frequently for preventive/oral health reasons or for tooth pain.     

First degree hotspots for OMFS recruitment 1967–2010: dental and medical schools where OMFS specialists and trainees were more likely to start their careers

Evidence around careers shows that many surgeons were inspired early in their career and this was often based on their undergraduate experience. In this context we have reviewed the location of the first degrees of oral and maxillofacial surgery (OMFS) consultants and specialty trainees to look for any patterns or trends. It has been shown that there is variation across medical schools when core surgical trainee recruitment is analysed. To our knowledge no previous paper has undertaken a similar analysis of medical and dental schools in the context of OMFS. The first-degree universities of OMFS specialists and trainees were compiled from the Medical and Dental Register, tabulated and analysed. There were 680 entries in total with dates of graduation ranging from 1967 - 2010. The relative frequency of first-degree locations based on the number of current places for medical and dental students was calculated to aid comparison. There are ‘hot-spots’ from where many OMFS specialists originate and also universities that rarely or never produce OMF surgeons. Reviewing these figures in the context of the number of places available to students and against time, points to areas where OMFS appears to be promoted, and others were the specialty has a low impact. The University of London leads the way for both medicine and dentistry-first trainees by a considerable margin. Glasgow is the next most productive for dentistry and Nottingham for medicine. The 13 current medical schools from which no OMFS specialists or trainees have originated are Brighton, Cambridge, Anglia Ruskin, Exeter, Hull, Keele, Lancaster, Norwich, Plymouth, Swansea, University of Central Lancashire (UCLan), and Warwick. Other new medical schools are opening this year. There are opportunities for all OMFS units and training rotations to look at ‘best practice’ for OMFS recruitment and apply as many inspiring interventions as they can in their local medical and dental schools, and in foundation and core training programmes.     

An oral disease prevention program for patients receiving radiation and chemotherapy

Thirteen years of treating more than 2,950 patients at the National Institute of Dental Research clinic have shown that a variety of potential oral sequelae associated with cancer therapy can be prevented, reduced in severity, or palliatively alleviated when the dental team has an opportunity to participate in the patient's care. The keystone of this success is based on early referral of the patient for dental consultation, treatment before the initiation of cancer therapy, and a well-defined orientation program to inform patients and their families about the difficulties they may experience. Meticulous attention to oral microbial control, prophylactic use of fluoride gels, and palliative treatment of soft tissue lesions may significantly reduce the oral morbidity associated with radiation and cytotoxic chemotherapy. Diligent personal oral health care and frequent dental recall appointments are recommended for the remainder of the patient's life. It has been our experience that patients who are not followed closely after irradiation therapy have an increased incidence of caries as a result of noncompliance with preventive regimens. The ethical and medicolegal responsibility to fully inform the patient of these recommendations lies with both the medical and dental personnel at the facility providing the radiation-chemotherapy service. The general dentist shares the responsibility for continuity of long-term oral health care.     

Oral and Maxillofacial Surgical simulation: efficacy for medical students

Oral and Maxillofacial Surgery (OMFS) is underrepresented in the medical curriculum with 90% of medical students reporting no exposure to the specialty in medical school. This can result in clinicians having problems recognising emergency presentations, and referrals being made inappropriately. OMFS trainees delivered an educational simulation course on common OMFS pathologies to medical students, with theory and hands-on, high-fidelity simulations that covered anatomy, emergency presentations, and the training pathway. Delegates were assessed immediately before, immediately after, and six-weeks after the course. There were significant improvements in knowledge six weeks after the course, with mean scores improving by 23% for knowledge of anatomy (p<0.01), 21% for emergency management of patients (p<0.01), and 22% for knowledge of the training pathway (p=0.04). There was a 58% increase in interest in OMFS and improved confidence for an oral examination. This study found that improvements in knowledge about concepts in OMFS were sustained and significant. Given the lack of representation of the specialty in medical school, high-fidelity simulation should be more widely adopted as an educational adjunct to help bridge the gap between taught theory and applied practice.     

Postoperative delirium in patients with head and neck oral cancer in the West of Scotland

Our aims were to determine the prevalence and association of postoperative delirium (POD) in head and neck (H&N) cancer patients undergoing free flap reconstruction at the oral and maxillofacial surgery (OMFS) unit, Queen Elizabeth University Hospital (QEUH) Glasgow, and to assess whether these determinants can be modified to optimise patient care and reduce the occurrence of POD. Delirium remains an important problem in the postoperative care of patients undergoing major H&N surgery, and early detection and management improve overall outcomes. The patient database containing details of the preoperative physical status (including alcohol misuse, chronic comorbidity, and physiological status) of 1006 patients who underwent major H&N surgery with free-flap repair at the QEUH from 2009-2019, was analysed. Factors associated with delirium were studied, identifying univariate associations as well as multivariate models to determine independent risk factors. The incidence of POD was 7.5% (75/1006; 53 male:22 female; mean (SD) age 65.41 (13.16) years). POD was strongly associated with pre-existing medical comorbidities, excess alcohol, smoking, a prolonged surgical operating time (more than 700 minutes), tracheostomy, blood transfusion, and bony free flaps. Those with POD were at an increased risk of postoperative wound and lung complications, and were more likely to require a hospital stay of more than 21 days. Presurgical assessment should identify risk factors to optimise the diagnosis and treatment of POD, and will enhance patient care by reducing further medical and surgical complications, and overall hospital stay.     

How Patients&apos; Lack of Knowledge About Oral Bisphosphonates Can Interfere With Medical and Dental Care

BackgroundOral bisphosphonate use has been associated with a small risk of developing oral osteonecrosis that occurs spontaneously or after the patient has undergone dental surgery. The authors conducted a study to determine whether patients taking bisphosphonates had knowledge about the medical indication for the therapy and the duration of treatment, as well as whether they had been educated by their physicians about possible adverse reactions.MethodsFrom June 2008 through April 2009, people seeking routine care in a dental clinic and who were being treated with bisphosphonates were invited to participate in the study. The participants were asked questions involving knowledge about the medical indications related to their taking bisphosphonates, the duration of their therapy and whether they had been educated about possible adverse reactions.ResultsThe authors interviewed 73 participants; 84 percent stated they knew why they were receiving bisphosphonate therapy. However, 80 percent said they were unsure about the duration of therapy, and 82 percent could not recall if they had been told about the risk of experiencing adverse reactions, including oral osteonecrosis, by their physicians.ConclusionPeople taking bisphosphonates may be unfamiliar with the drug and its possible adverse oral side effects.Clinical ImplicationsDentists should be prepared to educate patients about the risks of developing oral complications resulting from bisphosphonate use and the need for appropriate dental care. Questions regarding discontinuation of bisphosphonate therapy should be answered by the physician.     

Delays in the referral and treatment of oral squamous cell carcinoma

OBJECTIVE: To investigate the delays in referral and treatment of patients with oral cancer. DESIGN: A retrospective study. SETTING: District General Hospital Maxillofacial Unit (MFU). SUBJECTS: 100 consecutive patients with invasive squamous cell carcinoma of the oral cavity referred to Rotherham District General Hospital Maxillofacial Unit (RDGH MFU) between 15th March 1993 and 16th January 1998. METHOD: Information collected at the time of referral and treatment was examined retrospectively. RESULTS: In the patients studied 72% were male, mean age 61.2 years (sd = 11.2, range 37 to 88) and 28% female, mean age 65.6 years (sd = 16.7, range 29 to 90). The majority of referrals were from medical practitioners (56%) and most of the remainder being referred by dental practitioners (36%). The patient delay was found to be the most significant with only 39% presenting within 4 weeks, 29% delayed more than 3 months. There was no statistical correlation between T-stage, alcohol or cigarette use and the patient delay in presentation. Having presented to a medical or dental practitioner 69% were referred within 1 week. There were no significant differences between the T-stages presenting to either medical or dental practitioners or in their delay in referral for each stage. There was no significant difference in age or sex distribution between the populations presenting to general medical or general dental practitioners. General medical practitioners were more likely to refer a patient urgently. Patients referred directly to the MFU were seen quickly but those referred via an indirect route were delayed. 95% of patients were treated within 6 weeks of first consultation. CONCLUSION: The majority of practitioners refer patients with oral cancer within 1 week. The most significant delay is that caused by the patient. Some practitioners referred patients to inappropriate specialties, leading to indirect referrals. This results in additional delay in the referral and treatment pathway. Education of the public and primary health care workers should continue. Opportunistic screening of the oral mucosa should be part of the dental check up, with possible targeting of patients at greatest risk, particularly heavy drinkers and smokers.